The report is part of the Public Health Status and Forecast 2002 produced by the National Institute of Public Health and the Environment in the Netherlands. The report describes two complex parts of the Dutch Healthcare system: pharmaceuticals and medical devices, and the role of the stakeholders involved. Producers mainly determine the prices, despite regulation by the government and insurance companies. Pharmaceutical companies spend a lot of money to marketing. Marketing makes physicians less sensitive to price. Prescribers of medical devices often have insufficient information to prescribe the most efficient device. Besides the health status of the patient, the attitude and cultural background determine the use of pharmaceuticals. Medical need, participation, patient friendliness and social acceptance partly determine the use of medical devices. If policy remains unchanged, expenditure on pharmaceutical care will rise by 11% and expenditure on medical devices by 7% each year until 2006. This results from an increase in the number of prescriptions and a mean increase in price per prescription. These increases are due to demographic, socio-cultural developments and advances in medical technology. An analysis is given in the report.

Over the last four decades perinatal and infant mortality rates have decreased strongly in all countries of the European Union (EU). The declining trend for the Netherlands, however, has recently levelled off more strongly than for other EU countries and is stronger for perinatal than for infant mortality. Two questions arose: (1) Which risk factors can explain the unfavourable Dutch trends? And (2) How may the present situation be improved? With respect to the first question, four risk factors for perinatal mortality were specifically investigated: age of mother at birth (older and teenage mothers having increased risks), ethnic origin of the mother (most often increased risks), multiple births (increased risks for twins, even higher for larger (3 or more) multiplets) and smoking during pregnancy (increased risk for low birth weight and perinatal mortality). Over the past 25 years the percentage of Dutch children born with an older (35+) mother has increased from 5 to 20%. The average age of Dutch mothers at birth of their first child has increased simultaneously and faster than elsewhere and it is now the highest in the world. In the same period the number of children born to mothers with an ethnic origin has also increased from about 5 to 20 %. Several large Dutch minority groups (Turkish, Moroccan, and Surinam) have increased risks for perinatal mortality. Recently, immigrants and refugees from Eastern Europe, Asia and Africa have added to these groups with increased risks. Although accurate data are lacking, it is likely that this increase has been larger in the Netherlands than in several other EU countries. The number of Dutch children born as (one of) a multiplet rose from 2 % in 1980 to 3.5 % in 2000. Not only the increasing age of the mother, but also the concurrent increase in infertility and its treatments (hormonal and/or IVF) are responsible for the rise in multiplets. The Dutch multiple birthrate is now among the highest in Europe, although not for 'higher' mutliplets. Dutch women in the fertile age are among the most frequent smokers in the EU and Dutch women also are still smoking relatively much during pregnancy (20 %). The pattern of these risk factors could at least partly explain the relatively unfavourable development of the Dutch perinatal mortality rates. Nevertheless, these mortality rates have continued to decrease and other, positive, factors must have been at work as well. These would include improvements in living conditions and healthy lifestyle as well as improvements in prevention, healthcare and medical technology. The counterpart of the declining perinatal mortality rate, however, is the increased number of children that survive with a neurologic or cognitive disability. Dutch health care historically involves a high percentage of homebirths and the Dutch system is also known for its relatively low medical intervention rates. Comparative studies show that the performance of the Dutch system of perinatal care is as good as other European systems. In all countries, however, there remains a certain amount of probably or potentially avoidable perinatal mortality (6, respectively 19 % for the Netherlands). Taking into account the observed pattern and trends in risk factors as well as the relevant aspects of health care and prevention this report points at health policy options to improve health care and prevention during pregnancy and around birth in the Netherlands. Focusing on a multicultural approach to prevention and health care for pregnant women, more attention to quitting smoking during pregnancy, more effective screening before birth and improving the national information collection in this area are major opportunities for Dutch health policy.<br>

This definition report presents the starting-points and design of the Public Health Status and Forecasts 2002 (PHSF 2002). The aim is: to collect, analyse and integrate data and knowledge relevant for policy development in the field of public health and health care. The PHSF is characterised by: (1) the health status of the population as the main starting-point; (2) its function as an integral framework for the collected information; (3) its nationwide project status, reflecting contributions of experts both within and outside the National Institute of Public Health and the Environment (RIVM). To link up as closely as possible with the information needs for policy-making, PHSF will consist of: (1) a PHSF summarising report 2002, to be published in 2002, presenting an integrated, overall view of the developments in health status, the causes and consequences of these developments, and the possibilities for policy interventions; (2) thematic reports which will be published during the course, each characterised by a concise discussion of the relevant theme. So far five themes have been selected: (1) Health in the big cities; (2) Health promotion among specific groups; (3) Demand, supply and geographical distribution of health care; (4) Medicines and medical devices and (5) Care for the elderly. During the course of PHSF production new themes can be added; (3) the Monitor on Public Health and Health Care, an Intranet-accessible information system presenting regularly updated information on (developments in) public health, determinants and care.Within this design the PHSF should be seen as a supplier in continuum of information for public health policy-making. Just as during the realisation of earlier editions of the PHSF, an appeal will be made to research expertise, both within and outside the RIVM.<br>

What medicines are available at the moment? What developments are expected in the supply of medicines in the future and what are the possible consequences of new medicines for health and health care? These are the questions which have been answered by experts on17 illnesses and disorders important for public health. These were: breast cancer, lung cancer, colon and rectal cancer, diabetes mellitus, dementia, schizophrenia, depression, anxiety disorders, addiction, coronary heart disease, heart failure, stroke, pneumonia, asthma and COPD, rheumatoid arthritis, osteoarthrosis and osteoporosis. The forecasting period was divided into short (0-5 years), medium (5-10 years) and long term (10-20 years), which meant that expectations ranged from 'most probable' to 'most uncertain'. General aspects of medicines were also covered in this study, e.g. the production process from development to reimbursement, new search strategies, new vaccines for infectious diseases, gene therapy, pharmacogenomics, orphan drugs, undesirable and accidental effects of medicines, phyto-therapeutics and social acceptance of new medicines. The report concludes by sketching two scenarios for setting up pharmaceutical care in the future.

Mental disorders constitute an important societal and public health problem, being responsible for over 23% of (direct) health care costs. The use of mental health care services is still growing at a substantial rate. This review illustrates that there is a growing body of knowledge on specific determinants in the etiology of several mental disorders. There is, however, little known about the interrelationships between determinants in the causal chain leading to disorders. Personality traits, traumatic events in childhood, a low socio-economic status, extensive urbanization and rapid social changes in society are related to more than one mental disorder. Interventions influencing these generic determinants, or training to cope with them, will have the greatest potential health benefits. No definite conclusions can be drawn about the effects of interventions, influencing the determinants of mental disorders. Interventions, targeting several determinants at the same time are assumed to be the most promising. The effectiveness of secondary prevention of depression in the elderly and prevention of substance abuse through programs at school has proven sufficient for national implementation. Interventions targeted at family members of psychiatric patients has been seen to prevent the occurrence of distress and anxiety disorders. Investing in research on determinants of mental disorders is a prerequisite for making progress in prevention. Effective programmes should be nationally implemented. As there is practically no information on strategies for implementation within the field of mental disorder prevention, investments in this field are required.

The Public Health Status and Forecast (PHSF) describes the health status of the Dutch population. Previous editions of the PHSF described diseases in terms of mortality, prevalence and incidence. This pilot-study was conducted to investigate if there is also adequate information available in The Netherlands on health-related quality of life for diseases, and if this can be compared among diseases. This pilot study made use of a literature search on eight selected diseases to find information on generic quality of life and, where available, on patient characteristics, disease characteristics and health care factors. For breast cancer, visual impairments, osteoarthritis, and traffic accidents, the information was very limited. For the remaining half of the selected diseases (anxiety disorders, stroke, COPD/astma, diabetes) it was possible to describe the quality of life. Data on patient characteristics (age, education) were also available, but information on disease characteristics (severity) and health care factors was often lacking. In conclusion, the currently available information on quality of life can be used to complete the descriptions of the diseases in the PHSF. This pilot study will be applied to other diseases, with data being published in the 'National Compass on Public Health'.<br>

The goal of the study was to describe the health related quality of life for 53 diseases for publication in the National Public Health Compass, one of the websites of the Public Health Status and Forecast. A literature search on the quality of life conducted for all 53 diseases was confined to generic instruments and to Dutch studies published in the period 1990-2001. The quality of life, based on generic instruments, could be described for 24 diseases (45%). In the case of 6 diseases (11%), the only avalaible information was based on disease-specific instruments. For these diseases, only a reference was made to key publications. For 23 diseases, no information was found. In the future, additional information on quality of life for many diseases will be obtainable from new longitudinal studies. As far as applications for health policy are concerned, it would seem advisable to collect more data on disease characteristics related to quality of life.<br>

The International Classification of Impairments, Disabilities and Handicaps (ICIDH)) is being revised by WHO and its Collaborating Centres for the ICIDH. The Dutch WHO Collaborating Centre for the ICIDH in 1989. WHO issued a first proposal for revised ICIDH in July 1997, the Beta-1 draft, under the title International Classification of Impairments, Activities and Participation. Comments on this draft and results of field trials were used for the drafting of a second proposal, the Beta-2 draft that was issued in 1999. The new title of the Beta-2 draft, International Classification of Functioning and Disability, reflects the restructuring of the classification and the rewording of its classes. As much as possible the classification is formulated in neutral terms. Problems in the Dutch translation of the Beta-2 draft was issued in December 1999 and has been sent out on request to about 3000 persons and organisations. The present report summarises the activities of the Dutch Centre between August 1999 and September 2000, specifying the comments on the Beta-2 draft and the results of field trials.

Lifestyle factors and determinants of behaviour in specific target groupsomic groups are important target groups for health promotion. Those in low socio-economic groups have, comparatively speaking, the most unfavourable profile when it comes to lifestyle. In health policy documents, the need for focusing on specific target groups, in particular, migrants and low socio-economic groups, is emphasised. There is, however, a gap between proposed actions in health policy and actual local practice, where interventions take place. Important reasons for there being insufficient attention paid to specific target groups are the lack of political support for health promotion at the local level, and insufficient funds and professional capacity. In the near future, to cut across the unfavourable trends in risk behaviour in several specific target groups, changes in health promotion policy and practice are needed. Health Promotion can react to these unfavourabl trends, offering tailor-made services to specific target groups. In cooperation with the different parties involved, authorities should be able to create an environment where people are capable of making healthy choices and empowered to take their own responsibility in healthy and happy living.

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